Four Areas Where Radiology can Improve Cancer Care

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Modern cancer care urgently demands new approaches. Lives are at
risk, and an everincreasing number of cancer patients and complex examinations
constitute more of the radiologist’s workload than ever before. Faster and more
accurate diagnoses clearly support the end goal—better patient care—but
precisely how to achieve this has proven elusive.We spoke with key opinion
leaders from the Netherlands, Sweden, the UK, and the US to better understand
the changes affecting radiology, and listened as they weighed in on the most
important challenges and developments in the field.

Opportunities exist not only for radiology to improve traditional
reading and reporting functions, but also, critically, to further the new
collaborative paradigm that puts radiology at the forefront of diagnosis and
patient management.

I invite you to read what these experts have to say.

Mats Björnemo, Vice President of
Product Management at Sectra

Area 1: Developing and
facilitating closer collaboration with other departments, especially pathology

Integrated Diagnostics

Integrated diagnostics is a powerful new concept in cancer care.
Professor Dr. Bruce A. Friedman, Emeritus Professor of Pathology at the
University of Michigan Medical School, defined integrated diagnostics in a 2012
presentation as “the seamless collaboration among the diagnostic specialists,
most notably pathologists and radiologists.” The goals of integrated
diagnostics are straightforward: “To reduce the time and expense of diagnostic
processes and provide clinicians with practical and actionable results.” These
simple, recognizable goals come with tantalizing theorized rewards, including
radically reducing the time from when a patient first walks into a practice to
final diagnosis from weeks to days.

Professor Dr. Paul van Diest, head of the Department of Pathology
at University Medical Centre Utrecht, talks about what integrated diagnostics
could actually look like in practice:

No idea, but we are thinking about it all the time! This is
something that we started about a year ago. We are starting to get a feeling
that there is added value in bringing together diagnostic information from
different laboratory disciplines and trying to make more sense of the data,
rather than just looking at individual data from individual departments…it’s
based on bringing diagnostic information together from different disciplines
and trying to look for added value, so you need algorithms that mine these data
and find patterns that point to diseases or diagnoses in a better way.

Will integrated diagnostics actually come to pass, or will it
remain merely theoretical? Prof. van Diest answers: “It’s complicated, yes, but
it’s gaining more and more momentum—more and more people are starting to talk
about this in different parts of the world. The time is right to start doing
this.”

Before integrated diagnostics can step out of the realm of theory,
pathology and radiology must collaborate more closely than they do today.
Streamlined communication of concepts and images between radiology and
pathology facilitates the work of both departments. Prof. van Diest elaborates:

The first step in the chain is always imaging, and the second step
is usually tissue or cellular diagnosis. Now there always needs to be feedback
between the two disciplines: pathologists need to check whether the biopsy was
representative by correlating back to the images, and radiologists like to
know, if they made a diagnosis, that it’s correct; we like to see their results
and they like to see ours. So the closer we bring them together, the lower the
threshold is to look at each other’s results and images, provide the optimal
feedback, and learn from each other’s results.

But is close physical proximity required to achieve improved
feedback and learning? Not necessarily, according to Prof. van Diest, provided
that both parties are using the same technology:

A certain proximity is not always that important; you can do a lot
in a digital way. Sometimes you simply need to talk to people, and the optimal
feedback is not just through ones and zeroes.Having said that, working
digitally on both ends is quite important, because that tremendously
facilitates access to data and images.

Having radiology and pathology on the same IT platform also
reduces costs, not requiring separate systems. Beyond this, a shared system
facilitates the MDT (multidisciplinary team meeting) — the pathologist can
better participate with images on the same digital platform, ready for display
and discussion.

Dr.
Brendan Devlin, consulting radiologist since 1988 and former lead radiologist
of NIPACS in Northern Ireland, comments: “One of the drivers for less-than-full
pathology participation in the MDT has been the slowness of looking at
individual slides, changing the slides, looking at a different image and
changing the focus, etc.” He identifies a preferable scenario where “the opportunity
to have instantly available digital images, bookmarked by the pathologist in
advance, greatly facilitates their discussion.”

In
the MDT, instead of just sending reports between departments or to the
referring physician, the doctors involved come together to discuss their shared
cancer patients. Meetings often include radiology, pathology, oncology, and
surgery. Diagnoses and treatment plans are made with the combined expertise of
the group, with the members acting in concert to develop patient pathways and
treatment plans. Dr. Devlin elaborates: “We perform quality assurance and
review what has already been done…it’s a good opportunity for professional
discussion, which involves a degree of professional skepticism as well—everyone
tests how robust your case is, how robust your diagnosis.” The best decisions
for the patient are made based on all of the information and perspectives presented
at that high-powered table.

Area 2: Improving reading efficiency

Screening programs, more complicated examinations, and an aging
population have all contributed to the huge quantity of scans awaiting the
radiologist’s review. Fortunately, tools that improve reading efficiency allow
the radiologist to continue delivering the best possible care even in the face
of increasing demands.

I want to see that the PACS software radiologists are using is
attuned to their needs, and facilitates what they have to do, almost in
advance. The analogy would be the surgeon turning to the nurse of many years’
experience, looking for a particular instrument, and the nurse is standing
there with the instrument in hand, ready for the surgeon to take…I would like
to think of the software programs as knowing what we’re doing and facilitating
what we’re doing, so that we can concentrate not on the process but rather on
the diagnosis, which is really what we’re there for.

He provides specific examples of how software would facilitate
reading:

Examinations may have, nowadays, up to a couple of thousand
images, and we may have to review these images in multiple planes—MR systems
have images in multiple planes that must be reviewed and collated—so the more
we can have software that facilitates this, the better. Therefore, we’re looking
at an increasing tendency to index lesions in cancer cases, and at anatomical
registration, particularly for follow-up studies, so that we can more quickly
review the very many more surveillance scans that are now being requested—so
they can be done quickly, efficiently, and effectively.

Dr.
Stamatia Destounis, Fellow of the American College of Radiology and Partner at
Elizabeth Wende Breast Care in Rochester, New York, speaks about how certain
reading and screening tasks are time-consuming but indispensable, and how the
ability to perform all tasks at a single workstation improves efficiency:

It’s
great to be able to interface with all our different modalities—MRI,
ultrasound, and digital breast tomosynthesis—at one workstation. Reading the
DBT images takes a long time, and so does performing a screening ultrasound
examination, but these may provide more comprehensive care for the patient. I
don’t think there are any radiologists who feel that we’re spending too much of
our time on these additional studies; we’re happy to do them because we’re
finding lesions that need to be found.

The
number and complexity of the different systems and applications designed to
save time can sometimes have the opposite effect. Demay addresses the need for
seamless integration between different systems and applications:

We
perform ultrasound, MRI, and biopsy procedures at our main facility; we see
over 300 screening patients a day, and many stay for their results. But we also
have three satellites where we perform mammograms and ultrasounds, and our
radiologists are reading those studies remotely. Those patients may be waiting
at the satellite for their results as well, so we need everything to work
together seamlessly. The more integration we have with other systems and
applications the better, because that means one less click for the doctors.
Integration with our dictation and RIS systems helps doctors get through their
worklists, through their day, and reduces distractions. We want to provide our
radiologists with an environment where they can concentrate on reading, not on
how to navigate from application to application.

Area 3: Expediting the creation of more actionable reports

Rich and structured reports will allow the radiologist to provide
more-actionable reports in less time, contributing even more to the entire
patient-care team.

Rich reporting involves linking text in the diagnostic report to
images or other data, which will make reports more actionable not only for clinicians
but also for diagnosticians on subsequent review. Dr. Devlin describes how rich
reporting will improve the communication of diagnostic certainty and key
messages:

Starting at the basic level, I think it would be good if we could,
while describing a particular lesion in the report, click on a word and link it
to an image where we highlight a mass and change the view or color. The
clinician who is later reading the report could click on the highlighted word and
have the image pop up that best shows the abnormality. You try to make these
reports more real for people…it all has to do with transforming and
transmitting not just the diagnosis but also the diagnostic certainty level to
the clinician. Some reports are quite long, so the more we can make sure that
the actual messages are getting through, the better.

Dr. Devlin stresses that, though it sounds easy, successful
implementation will require strong collaboration with clinicians: “It’s not
that we can’t do it; it’s just not as easy as it might sound. It will demand a
lot of work with clinicians to explore that reality.”

Structured reports will standardize both information layout and
terminology, expediting report creation and presenting key information in an
easier-to-read format for clinicians and other diagnosticians. But important
considerations must be addressed before they will become common in radiology.

Dr.
Devlin discusses how the structured report should be intuitively integrated
with the image-reading process: “We have to make sure that it doesn’t actually
damage the diagnostic process by making people focus too much on the mechanics
of populating the fields of the report; it needs to be incorporated into the
process of how the radiologist looks at the studies and not distract them from
the essential intense scrutiny of the image findings.”

He
goes on to identify an important benefit: “Structured reporting is good for
ensuring that there are no gaps in the report. If the fields are there and they’re
empty, then you know you probably haven’t said anything about the internal
mammary nodes, for example, and that you probably should.”

“Several
facilities have structured reporting, with systems that characterize lesions
and give locations in the breast; doctors are able to just click on things, and
the structured report works very well.” But dictation has long been a standard
reporting practice, and to compete, structured reports must contain robust
selection options to accommodate the nuance of what the radiologist

must
express. Dr. Destounis explains:

There’s
always the limitation of the drop-down box in how many choices you have, and
when you’re dictating the lesion characteristics, the lesion location, or the
exam, the available choices may not reflect exactly what you want to say. But I
do know that many facilities and hospitals have structured reporting. If we get
there, the hope is that the system is accommodating, trainable, and easy to
use, and has a lot of choices. Because if I have to edit most of the report
because the choices are not there, then it doesn’t really help me—it makes my
life miserable. In a multi-radiologist practice, you’ll have to figure out how
to agree on how the report should be structured, and what the most important
features of an integrated dictation system are.

Area 4: Investing in an
information infrastructure with a consolidated patient archive and cross-enterprise workflow

A consolidated patient archive provides access to all patient
information, resulting in faster and more accurate diagnoses; a
cross-enterprise workflow balances workloads and enables collaboration with
other doctors and facilities when specialty expertise and second opinions are required.
Both are pivotal to successful patient-centered cancer care.

”MDT preparation requires no human interaction in terms of sending
CDs, or importing this, that, or the other. It’s all an intrinsic part of the
design and configuration of the system. This saves a lot of time and improves
the quality of decision-making: there is no incomplete decision-making made on
the basis of incomplete data. Every time manual interaction is required, the
possibility for delay increases, because things don’t happen. If the post doesn’t
arrive, we can’t have the discussion.

That kind of thing is to be avoided at all costs, and a joined-up
IT system achieves that.”

Dr. Devlin offers concrete proof of a consolidated, integrated
archive’s success: A NIPACS MDT audit revealed that 100% of completed studies
and authorized reports were available for review during the audit period.

The Stockholm VNA

Stockholm County represents one of the many healthcare providers
and governing bodies now seeking to define visions of more patient-centered
healthcare. Gustav Alvfeldt, Information Architect and Project Manager with the
Stockholm County Council, spoke at a conference in August about their recent
VNA rollout. A VNA, or vendor-neutral archive, is one option for enterprise clients
looking for a consolidated patient record archive and workflow function.

Alvfeldt describes two overarching goals of their archive: “To
avoid moving the patient around unnecessarily, and to use the resources of the
region rather than only those of the hospital.” The Stockholm region contains
the largest number of patients in Sweden, comprising 2.2 million inhabitants
and 2000 healthcare providers. Five public and five private hospitals offer
radiology

services, each with their own storage solutions, RIS and PACS, and
together provide 1.6 million exams every year—and all will be connected through
the VNA.

But the archive does not stop at centralizing radiology records.
The VNA will also house and structure data from other departments to enable
closer collaboration between them and support the county’s patient-oriented
perspective. The county decided to implement a regional cloud-based VNA with
built-in workflow intelligence to enable the efficient flow of images and
information between all healthcare providers and ultimately improve the quality
of care. Storing the archive in a cloud allows the county to focus on
healthcare issues, leaving the vendor responsible for hardware maintenance and
upgrades. “We wanted a VNA on steroids—not just storage, but intelligence
around the storage…a total information infrastructure” says Alvfeldt.

Why is such an infrastructure important?
Alvfeldt explains:

Patients
today move around a lot more. For radiology this means that, before any given
exam, the healthcare provider has to look for previous history from any of the
other radiology departments in the region. In cancer care, having the complete
patient history is crucial to making the correct diagnosis.

Doctors
who know a patient’s complete history will not schedule that patient for
unnecessary, redundant examinations if records of previous exams that suffice
are already in the archive. Avoiding redundant exams is important for many
reasons: expediting diagnosis and overall treatment, minimizing radiation
exposure, reducing costs, and increasing overall patient satisfaction.

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